Survival improvement in Child-Pugh C cirrhotic patients with hepatocellular carcinoma diagnosed during 1990-2002.

OBJECTIVES: The aim of this study was to describe the evolution of diagnostic modalities, treatment and survival in cases of hepatocellular carcinoma (HCC) between 1990 and 2002 in Calvados. METHODS: All cases registered as HCC in the Calvados Tumour Registry from 1990 to 2002 were retrospectively reviewed. Incidence rates were standardized in comparison to the world reference population. The Kaplan-Meier method was used for survival analysis, and the log-rank test and Cox's model were used to compare patient survival according to demographic and tumour characteristics, as well as diagnosis period. Multivariate analysis were performed to determine independent prognostic factors and to assess the impact of the diagnosis period on survival. RESULTS: From 1990 to 2002, 729 cases registered as HCC were retrospectively validated. Standard incidence rates were 11.1/100,000 in men and 1.9/100,000 in women. Mean age was 66.6+/-11.8 years. Cirrhosis was present in 90.4% of cases. The cause of cirrhosis was alcohol in 66.8% of cases, HCV in 12.5%, HBV in 2.9%, haemochromatosis in 3.5%, and "other" in 13.1%. Curative treatment was possible in 14.7% of cases. Median survival was 7.15 months. On multivariate analysis, male gender, age greater than 70 years, Child-Pugh C (advanced-stage) cirrhosis, portal or suprahepatic venous thrombosis, alpha-fetoprotein (AFP) level greater than 200 ng/mL and non-curative treatment were poor prognostic factors. However, the diagnosis period was a good prognostic factor, associated with survival improvement over time in Child-Pugh C patients independent of tumour size, but not in Child-Pugh A and B. CONCLUSION: From 1990 to 2002, improvement in the survival of Child-Pugh C cirrhosis patients with HCC was observed that was apparently essentially attributable to better management of cirrhosis, and an improved balance between treatment and the degree of portal hypertension and hepatocellular insufficiency.

Pancreatic cancer: incidence, treatment and survival trends--1175 cases in Calvados (France) from 1978 to 2002.

AIM: To assess the trends in incidence, therapeutic modalities and survival of pancreatic cancer between 1978 and 2002 in a well-defined population, as recorded in the Calvados digestive cancer registry database. PATIENTS AND METHODS: All patients living in Calvados with a diagnosis of pancreatic cancer were registered. Clinical data and treatment modalities were prospectively recorded. This 25-year database was divided into five 5-year periods. Data were compared using log-rank tests and the Cox model. RESULTS: A total of 1175 cases of pancreatic cancer (617 men, 558 women) were registered. Its incidence increased with an average annual coefficient of +2.8% in men and +5.1% in women. Therapeutic modalities changed over the five time periods: surgical resection increased from 6.8 to 13.4% (median survival 15 months) while radiation therapy and/or chemotherapy also increased from 5.5 to 13.2%. Palliative surgery decreased from 54.6 to 32.0% and favored interventional endoscopic techniques. Postoperative mortality decreased significantly. Survival increased significantly over the five time periods, although the median survival time remained stable (4 months). CONCLUSION: From 1978 to 2002, pancreatic cancer incidence increased in Calvados (France). Therapeutic modalities changed, with endoscopic treatments preferred over palliative surgery. The improvement in survival could be explained by the decrease in postoperative mortality.

Access to care, socioeconomic deprivation and colon cancer survival.

BACKGROUND: The influence of socioeconomic environment on cancer survival has been established in numerous studies in the EU and the US, prognosis being constantly poorer for the most underprivileged patients. AIM: To investigate the influence of distance to care centre and deprivation on colon cancer survival, using a multilevel Cox model and taking into account cancer stage at diagnosis and treatment modalities. METHODS: The study population comprised all cases of colon cancer diagnosed between 1997 and 2000 in two French areas covered by specialized cancer registries (n = 2066). RESULTS: Road distance to the nearest reference care centre was associated with poorer prognosis even after adjustment for stage at diagnosis (P for trend = 0.01). Subgroups analysis showed that this association was maximal for patients with advanced cancer [RR = 1.27 (1.04-1.51); P for trend = 0.015] for whom access to chemotherapy varying according to distance explained the major part of geographic inequalities in survival. CONCLUSIONS: The major effect of distance from reference care centre on survival suggests that current regional health planning does not guarantee equity in cancer management. Improvement in access to adjuvant therapy, especially for patients with advanced cancers, seems crucial for reducing geographic disparities in colon cancer survival.

Effectiveness of intensive insulin therapy by multiple daily injections and continuous subcutaneous infusion: a comparison study in type 2 diabetes with conventional insulin regimen failure.

OBJECTIVE: To compare the effectiveness of two intensified insulin regimens, i.e., pump delivery versus multiple daily injections in patients with type 2 diabetes not optimally controlled with conventional insulin therapy. RESEARCH DESIGN AND METHODS: Seventeen type 2 diabetes patients uncontrolled by two daily injections of regular plus NPH were randomly assigned in a cross-over fashion to either three daily injections of lispro plus NPH or pump device delivering lispro. HbA1c, 6 points capillary blood glucose, 24-hour continuous glucose monitoring system tracings and global satisfaction score were evaluated at the end of each 12-week treatment period. RESULTS: HbA1c decreased from 9.0+/-1.6% to 8.6+/-1.6% with multiple injections and 7.7+/-0.8% with pump device (p<0.03). Capillary blood glucose was lowered at all time-points with pump, but only at morning with multiple injections (p<0.01). Compared to conventional therapy, pump reduced hyperglycemic area under curve by 73% (p<0.01), but multiple injections by only 32% (p=0.08). Rate of hypoglycemia was not increased and patient's satisfaction was comparable with both intensive treatments. CONCLUSIONS: Pump therapy provides a better metabolic control than injection regimens, and seems to be safe and convenient in patients with type 2 diabetes who fail to respond to conventional insulin therapy.

Comparison of a guaiac based and an immunochemical faecal occult blood test in screening for colorectal cancer in a general average risk population.

BACKGROUND: The guaiac faecal occult blood test (G-FOBT) is recommended as a screening test for colorectal cancer but its low sensitivity has prevented its use throughout the world. METHODS: We compared the performances of the reference G-FOBT (non-rehydrated Hemoccult II test) and the immunochemical faecal occult blood test (I-FOBT) using different positivity cut-off values in an average risk population sample of 10,673 patients who completed the two tests. Patients with at least one test positive were asked to undergo colonoscopy. RESULTS: Using the usual cut-off point of 20 ng/ml haemoglobin, the gain in sensitivity associated with the use of I-FOBT (50% increase for cancer and 256% increase for high risk adenoma) was balanced by a decrease in specificity. The number of extra false positive results associated with the detection of one extra advanced neoplasia (cancer or high risk adenoma) was 2.17 (95% confidence interval 1.65-2.85). With a threshold of 50 ng/ml, I-FOBT detected more than twice as many advanced neoplasias as the G-FOBT (ratio of sensitivity = 2.33) without any loss in specificity (ratio of false positive rate = 0.99). With a threshold of 75 ng/ml, associated with a similar positivity rate to G-FOBT (2.4%), the use of I-FOBT allowed a gain in sensitivity of 90% and a decrease in the false positive rate of 33% for advanced neoplasia. CONCLUSIONS: Evidence in favour of the substitution of G-FOBT by I-FOBT is increasing, the gain being more important for high risk adenomas than for cancers. The automated reading technology allows choice of the positivity rate associated with an ideal balance between sensitivity and specificity.

Social determinants of access to reference care centres for patients with colorectal cancer--a multilevel analysis.

BACKGROUND: Although social disparities in survival for patients with cancer are documented in an increasing number of papers, knowledge on the underlying mechanisms concerning screening, diagnosis, treatment or follow-up, is relatively poor. Our study was aimed at investigating the social determinants of access to reference cancer care centres for surgery for colorectal cancer in France. METHODS: Retrospective analysis was conducted on population-based data from a specialised cancer registry (County of Calvados, France). The population consisted of 5156 patients with surgical treatment for colorectal cancer recorded between January 1st 1981 and December 31st 2000. RESULTS: The probability of being cared for in a reference care centre was 1.3-fold lower for people living in a deprived district (mean income < 15000 euros) and 3-fold lower for people living in a district where more than 7% of houses were devoid of bath and shower in comparison with districts where this rate was under 2%. After adjustment for distance from reference care centre, the probability of being cared for in a reference care centre was still over one third lower for people living in a district with more than 7% of houses devoid of bath and shower. Social disparities in management of patients with colorectal cancer have increased in the last decade. The reduction of access to reference care with distance was stronger in elderly patients. CONCLUSIONS: There is a social and geographical determination of type of treatment centre for care management of colorectal cancer in France. Special attention needs to be paid to the high quality of care management in non-specialised care centres in order to avoid an increased social gradient in cancer mortality in France.

Socioeconomic and geographic determinants of survival of patients with digestive cancer in France.

Using a multilevel Cox model, the association between socioeconomic and geographical aggregate variables and survival was investigated in 81 268 patients with digestive tract cancer diagnosed in the years 1980-1997 and registered in 12 registries in the French Network of Cancer Registries. This association differed according to cancer site: it was clear for colon (relative risk (RR)=1.10 (1.04-1.16), 1.10 (1.04-1.16) and 1.14 (1.05-1.23), respectively, for distances to nearest reference cancer care centre between 10 and 30, 30 and 50 and more than 90 km, in comparison with distance of less than 10 km; P-trend=0.003) and rectal cancer (RR=1.09 (1.03-1.15), RR=1.08 (1.02-1.14) and RR=1.12 (1.05-1.19), respectively, for distances between 10 and 30 km, 30 and 50 km and 50 and 70 km, P-trend=0.024) (n=28 010 and n=18 080, respectively) but was not significant for gall bladder and biliary tract cancer (n=2893) or small intestine cancer (n=1038). Even though the influence of socioeconomic status on prognosis is modest compared to clinical prognostic factors such as histology or stage at diagnosis, socioeconomic deprivation and distance to nearest cancer centre need to be considered as potential survival predictors in digestive tract cancer.

Social and geographic disparities in access to reference care site for patients with colorectal cancer in France.

The aim of this study was to investigate the relationship between social and geographic characteristics and the type of care centre for initial colorectal surgery in France. Patients living far from a reference cancer site were less frequently treated in a reference cancer site than those who were living near a reference cancer site OR(a)=(0.50 (0.33-0.76)). As for topography and emergency presentation, place of residence (urban/rural), occupation and marital status were not associated with the type of the care centre. Improvements in diagnosis and treatment and of clinical practice guidelines are therefore crucial to ensure equality in health care in France.